INTRODUCTION TO HEDIS 2018

Transcription

1 INTRODUCTION TO HEDIS 2018 Presented by the Quality Improvement Department at Gold Coast Health Plan Ventura County s Medi-Cal Managed Care Plan Serving Ventura County Since July 1, 2011

2 Contents I. What is HEDIS? II. HEDIS Measures GCHP Reports III. HEDIS Measure Definitions III. Reasons for Low HEDIS Rates IV. How to Improve Your HEDIS Rates

3 What is HEDIS?

4 What is HEDIS? HEDIS is a standardized set of performance measures called Healthcare Effectiveness Data Information Set, which are developed and maintained by the National Committee for Quality Assurance (NCQA).

5 Who participates in HEDIS? More than 90% of America s health plans (Medicare, Medicaid, and commercial) participate in HEDIS quality reviews. California s Medi-Cal managed care plans are mandated by the state Department of Health Care Services (DHCS) to report HEDIS measures annually.

6 Purpose of HEDIS Health plans use HEDIS reviews to: Evaluate quality of care and services provided to health plan members. Evaluate accessibility of care. Develop performance improvement initiatives. Perform outreach to providers and members. Compare performance with other health plans.

7 Reporting HEDIS Rates HEDIS measures evaluate the previous year s clinical data. For example, most HEDIS rates reported in 2018 are based on clinical services performed in Some measures, such as Cervical Cancer Screening, look for services performed up to five years prior to the reporting year. Results of HEDIS reviews are reported to DHCS and NCQA in June each year. GCHP distributes HEDIS Provider Report Cards and Performance Feedback Reports every other month.

8 What does HEDIS measure? HEDIS consists of 91 measures across six domains of care: 1. Effectiveness of Care 2. Access / Availability of Care 3. Experience of Care 4. Utilization and Risk Adjusted Utilization 5. Health Plan Descriptive Information 6. Measures Collected Using Electronic Clinical Data Systems

9 Clinical Data Reviewed for HEDIS Reporting Claims data Encounter data Pharmacy data Medical records Member data Provider data Supplemental clinic data such as: Lab Vision Immunization Electronic medical records

10 Two Types of Measures Hybrid measures Population size reviewed: Sample size of up to 411 eligible members randomly selected Require reviewing claims, encounter, and supplemental data (e.g., labs, Rx, vision, CAIR, etc.). Require reviewing medical record documentation to validate if members received the service or care being measured. Admin measures Population size reviewed: Entire eligible population Requires reviewing only claims, encounter and supplemental data (e.g., labs, Rx, vision, CAIR, etc.) No medical record reviews required.

11 HEDIS Measures GCHP Reports

12 HEDIS Measure 1 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Type of Measure Domain Sub-Domain Hybrid Effectiveness of Care Prevention & Screening 2 Childhood Immunization Status Hybrid Effectiveness of Care Prevention & Screening 3 Immunizations for Adolescents Hybrid Effectiveness of Care Prevention & Screening 4 Cervical Cancer Screening Hybrid Effectiveness of Care Prevention & Screening 5 Breast Cancer Screening Admin Effectiveness of Care Prevention & Screening 6 Depression Screening and Follow-Up for Adolescents and Adults Admin National Quality Strategy Domain: Community / Population Health Preventive Care and Screening 7 Asthma Medication Ratio Admin Effectiveness of Care Respiratory Conditions 8 Controlling High Blood Pressure Hybrid Effectiveness of Care Cardiovascular Conditions 9 Comprehensive Diabetes Care Hybrid Effectiveness of Care Diabetes 10 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Admin Effectiveness of Care Overuse / Appropriateness 11 Use of Imaging Studies for Lower Back Pain Admin Effectiveness of Care Overuse / Appropriateness 12 Annual Monitoring for Patients on Persistent Medications Admin Effectiveness of Care Medication Management 13 Children and Adolescent Access to PCPs Admin Access & Availability of Care Access & Availability of Care 14 Prenatal and Postpartum Care Hybrid Access & Availability of Care Access & Availability of Care 15 Well-Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life Hybrid Utilization & Risk Adjusted Utilization 16 Ambulatory Care Admin Utilization & Risk Adjusted Utilization Utilization Utilization

13 HEDIS Measure Definitions (Measures reported by GCHP)

14 Gold Coast Health Plan (GCHP) is the Medi-Cal managed care health plan for Ventura County. This means that GCHP must follow the guidelines as directed by the state Department of Health Care Services (DHCS). While the HEDIS measures are a standard set of measures used nationally, GCHP is only required to report those specific to Medi-Cal managed care. On a bi-monthly basis, GCHP gives it s provider partners a report card that reflects those measures reported specifically by GCHP. Those measures will be identified throughout the remaining slides.

15 Domain: Effectiveness of Care Sub-Domain: Prevention and Screening

16 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents (WCC) The percentage of 3- to 17-year-old children and adolescents who had an outpatient visit with a PCP or OB / GYN and who received ALL of the following services during the 2017 measurement year: BMI Percentile Counseling for nutrition Counseling for physical activity Three separate rates are reported for each service. Data reviewed to identify compliance with measure: Claims and encounter data Medical records Hybrid Measure

17 Codes to Identify WCC Codes used to identify BMI percentile in children and adolescents Description ICD-10-CM Diagnosis BMI pediatric, less than 5 th percentile for age Z68.51 BMI Pediatric, 5 th percentile to less than 85 th percentile for age Z68.52 BMI Pediatric, 85 th percentile to less than 95 th percentile for age Z68.53 BMI Pediatric, greater than or equal to 95 th percentile for age Z68.54 Note: The BMI percentile ranking is based on the Centers for Disease Control and Prevention s (CDC) BMI-for-age growth charts and indicates the relative position of the child s BMI compared among others in the same gender and age group.

18 Codes to Identify WCC continued Codes used to identify Nutrition Counseling Description HCPCS CPT ICD-10-CM Diagnosis Nutrition Counseling Dietary counseling and surveillance Z71.3 Medical nutrition therapy; reassessment and subsequent G0270 intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (two or more individuals Face-to-face behavioral counseling for obesity, 15 minutes Weight management classes, non-physician provider, per session G0271 G0447 S9449 Nutrition classes, non-physician provider, per session Nutrition counseling, dietician visit S9452 S9470

19 Codes to Identify WCC continued Codes used to identify Physical Activity Counseling Description HCPCS ICD-10-CM Diagnosis Face-to-face behavioral counseling for obesity, 15 minutes Exercise classes, non-physician provider, per session G0447 S9451 Encounter for examination for participation in sport Z02.5 Codes used to identify Outpatient Visit Description CPT HCPCS UBREV Outpatient Visits , , , , , , , , 99411, 99412, 99429, 99455, G0402, G0438, G0439, G0463, T , , , 0982, 0983

20 Childhood Immunization Status (CIS) The percentage of 2-year-old children who had the following childhood immunizations on or before their 2 nd birthday: 4 DTaP* (diphtheria, tetanus, and acellular pertussis) 3 IPV* (polio) 1 MMR (measles, mumps, rubella) 3 HiB* (H influenza type B) 3 Hep B (Hepatitis B) newborn Hep B vaccine administered during eight-day period after birth is acceptable 1 VZV (chicken pox) 4 PCV* (pneumococcal conjugate) 1 HepA 1 (Hepatitis A) RV 1 * (Rotavirus) Any of the following on different dates of service: At least two doses of the two-dose rotavirus vaccine At least three doses of the three-dose rotavirus vaccine At least one dose of the two-dose rotavirus vaccine and at least two doses of the threedose rotavirus vaccine 2 Influenza 1 Data reviewed to identify compliance with measure: Claims and encounter data Medical records CAIR Immunization Registry Hybrid Measure * Do not count a vaccination administered prior to 42 days after birth. 1 Not reported by GCHP

21 Codes to Identify CIS Codes used to identify anaphylaxis reactions ICD-10-CM Diagnosis T80.52XA T80.52XD T80.52XS Description Anaphylactic reaction due to vaccination, initial encounter Anaphylactic reaction due to vaccination due to subsequent encounter Anaphylactic reaction due to vaccination, sequela Note: Document anaphylaxis to any particular vaccine

22 Codes to Identify CIS (continued) Codes used to identify immunizations administered Immunization Description CPT HCPCS CVX DTaP / DTP 90698, 90700, 90721, , 50, 106, 107, 110, 120 Hepatitis B 90723, 90740, 90744, 90747, G , 44, 45, 51, Hepatitis A , 83, 85 Polio (IPV) 90698, 90713, , 89, 110, 120 Influenza 90655, 90657, 90661, 90662, 90673, G , 135, 140, 141, 150, 153, 155, 158, 161 Measles Mumps Rubella Measles, Mumps, Rubella 90707, , 94 (MMR) Measles / Rubella Pneumococcal Conjugate 90669, G , 133, 152 (PCV) Rotavirus 90680, , 119, 122 Varicella Zoster (VZV) 90710, , 94 Hib , 90698, 90721, , 46-51, 120, 148

23 Codes to Identify CIS (continued) History or Disease Codes Disease description Chicken Pox Measles Mumps Rubella ICD-10 CM Diagnosis B01.0-B02.9 B05.0-B05.9 B26.0-B26.9 B06.00-B06.9 Hepatitis A B15.0, B15.9 Hepatitis B B16.0-B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51

24 Immunization for Adolescents (IMA) The percentage of 13-year-old adolescents who had the following immunizations: 1 Meningococcal between the member s 11 th and 13 th birthday 1 Tdap between the member s 10 th and 13 th birthday 2-dose or 3-dose series of HPV vaccine with different dates of service between the member s 9 th and 13 th birthday Four rates are reported: One rate for each immunization One combo rate reported showing the percentage of adolescents who had all three immunizations Data reviewed to identify compliance with measure: Claims and encounter data Medical records CAIR Immunization Registry Hybrid Measure

25 Codes to Identify IMA Codes used to identify exclusions for the IMA measure Description Anaphylactic reaction due to vaccination Anaphylactic reaction due to serum Anaphylactic reaction due to vaccination ICD-10-CM T80.52XS T80.52XD T80.52XA Codes used to identify Administered Vaccinations for the IMA measure Description CPT CVX HPV Vaccine Administered Tdap Vaccine Administered Meningococcal Vaccine Administered Note: There must be evidence on the claim for both the appropriate CPT and CVX codes in order to be considered compliant for the measure

26 Cervical Cancer Screening (CCS) Measures the percentage of women, between the ages of 21 to 64, who had one of the following cervical cancer screenings: 1. Women, ages 21 to 64, who had a cervical cytology screening within the last three years 2. Women, ages 30 to 64, who had a cervical cytology / HPV co-screening within the last five years One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Medical records Labs Hybrid Measure

27 Codes to Identify CCS Codes used to identify Cervical Cancer Screenings Description CPT HCPCS UBREV LOINC Cervical Cytology 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, HPV 87620, 87621, 87622, 87624, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q , , , , , , , , , G , , , , , , , , , , , , , Codes used to identify women excluded from the CCS measure Description ICD-10-CM ICD-10-PCS CTP Absence of Cervix Q51.5, Z90.710, Z90.12 OUTC0ZZ, OUTC4ZZ, OUTC7ZZ, OUTC8ZZ 51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58458, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58953, 58954, 58956, 59135

28 Breast Cancer Screening (BCS) Measures the percentage of women, between the ages of 50 to 74, who had a mammogram to screen for breast cancer any time between October 1, 2015 and December 31, One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Administrative Measure

29 Codes to Identify BCS Codes used to identify Mammograms Description CPT HCPCS UB Rev Mammography (Screening Mammography, Digital Breast Tomosynthesis, Digital Mammography) 77055, 77056, , 77062, , 77066, G0202, G0204, G , 0403 Medical exclusions that do not meet the intent of the measure are: Bilateral mastectomy Unilateral mastectomy with a bilateral modifier Two unilateral mastectomies with service dates 14 days or more apart History of bilateral mastectomy Any combination of codes that indicate a mastectomy on both the left and right side on the same or different dates of service.

30 Codes to Identify BCS (continued) Codes used to identify exclusions Description ICD-10-CM ICD-10-PCS CPT CPT Modifier Bilateral Mastectomy OHTVOZZ Unilateral Mastectomy with bilateral modifier Unilateral Mastectomy - Right Unilateral Mastectomy - Left Absence of Right Breast Z90.11 Absence of Left Breast Z90.12 History of Bilateral Z90.13 Mastectomy 19180, 19200, 19220, 19240, HTT0ZZ 19180, 19200, 19220, 19240, HTU0ZZ 19180, 19200, 19220, 19240, RT -LT

31 Preventive Care and Screening National Quality Strategy Domain: Community / Population Health

32 Depression Screening and Follow-Up for Adolescents and Adults (DSF) The percentage of patients ages 12 years and older screened for clinical depression using a standardized tool and, if screened positive, who received follow-up care. One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Administrative measure

33 Screening Tools for DSF Approved age-appropriate screening tools Age Appropriate screening tool Adolescent (12-17) Patient Health Questionnaire (PHQ-9) Mood Feeling Questionnaire (MFQ) Patient Health Questionnaire (PHQ-9M) Center for Epidemiologic Studies PRIME MD-PHQ2 Depression Scale (CES-D) Beck Depression Inventory Fast Screen PROMIS Depression (BDI-FS) Adult (18+) Patient Health Questionnaire (PHQ-9) PRIME MD-PHQ2 Beck Depression Inventory Fast Screen (BDI-FS or BDI-II) Center for Epidemiologic Studies Depression Scale Depression Scale (DEPS) Duke Anxiety Depression Scale (DADS) Geriatric Depression Scale (GDS) Cornell Scale for Depression in Dementia (CSDD) Edinburgh Postnatal Depression Scale (EPDS) My Mood Monitor (M-3) PROMIS Depression Clinically Useful Depression Outcome Scale (CUDOS)

34 Codes to Identify DSF Codes used to identify Depression Depression Positive for Depression No Depression or no symptoms that require follow-up HCPCS LOINC SNOMED CT US Edition G8431 G8510 G , , , , , , , , , , , G G

35 Codes to Identify DSF (continued) Codes used to identify a follow-up behavioral health encounter with or without a telehealth modifier including assessment, therapy, collaborative care, medication management, acute care and, if applicable, telehealth encounters. CPT 90791, 90792, , , , 90849, 90853, 90865, , 90875, 90876, 90880, CPT Telehealth Modifier -95 -GT HCPCS SNOMED CT US Edition UBREV G0155, G0176, G0177, G0409 G0411, G0502, G0503, G0507, H0002, H0004, H0031, H0034- H0037, H0039, H0040, H2000, H2001, H2010 H2020, M0064, S0201, S9480, S9484, S , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 0907, , 0919

36 Codes to Identify DSF (continued) Codes used to identify a follow-up outpatient visit with a diagnosis of depression or other behavioral health condition, with or without telehealth modifier. ICD-10-CM CPT CPT Telehealth Modifier F01.51, F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, , -95 F21 F24, F25.0, F25.1, F25.8, F25.9, F28, F29, 99078, GT F30.10 F30.13, F30.2-F30.4, F30.8, F30.9, F31.0, 99205, F F31.13, F31.2, F F31.32, F31.4, 99215, F31.5, F F31.64, F F31.78, F31.81, 99220, F31.89, F31.9, F32.0, F32.1-F32.5, F32.8, F32.81, 99245, F32.89, F32.9, F33.0 F33.3, F33.40-F33.42, F33.8, 99345, F33.9, F34.0, F34.1, F34.8, F34.81, F34.89, F34.9, 99350, F39, F42, F42.2-F42.4, F42.8, F42.9, F43.0, F , F43.12, F43.20-F43.25, F43.29, F43.8, F43.9, 99397, F44.89, F53, F60.0-F60.7, F60.81, F60.89, F60.9, 99404, 99411, F63.0, F63.1-F63.3, F63.81, F63.89, F63.9, F F68.13, F68.8, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F90.0-F90.2, F90.8, F90.9, F91.0-F91.3, F91.8, F91.9, F93.0, F93.8, F93.9, F94.0-F94.2, F94.8, F94.9 HCPCS UBREV SNOMED CT US Edition G0463, T , 0513, 0516, 5017, , , 0982, 0983 Due to space limitations, please click here to see the SNOMED CT codes.

37 Codes to Identify DSF (continued) Codes used to identify a telephone visit with a diagnosis of depression of behavioral health condition ICD-10-CM CPT SNOMED CT US Edition 98966, Due to space 98967, limitations, 98968, please click 99441, here to see the 99442, SNOMED CT codes. F01.51, F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F21 F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F30.10 F30.13, F30.2-F30.4, F30.8, F30.9, F31.0, F F31.13, F31.2, F F31.32, F31.4, F31.5, F F31.64, F F31.78, F31.81, F31.89, F31.9, F32.0, F32.1- F32.5, F32.8, F32.81, F32.89, F32.9, F33.0 F33.3, F33.40-F33.42, F33.8, F33.9, F34.0, F34.1, F34.8, F34.81, F34.89, F34.9, F39, F42, F42.2-F42.4, F42.8, F42.9, F43.0, F43.10-F43.12, F43.20-F43.25, F43.29, F43.8, F43.9, F44.89, F53, F60.0-F60.7, F60.81, F60.89, F60.9, F63.0, F63.1-F63.3, F63.81, F63.89, F63.9, F68.10-F68.13, F68.8, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F90.0-F90.2, F90.8, F90.9, F91.0-F91.3, F91.8, F91.9, F93.0, F93.8, F93.9, F94.0-F94.2, F94.8, F94.9 Codes used to identify a follow-up with a case manager with documented assessment of depression symptoms (any encounter that addresses depression symptoms) CPT HCPCS SNOMED CT US Edition T1016, T1017, T2022, T , , , , , , , , , , , , , , , , , , , , , , , , ,

38 Codes to Identify DSF (continued) Dispensed antidepressant medication Description Miscellaneous antidepressants Monoamine oxidase inhibitors Phenylpiperazine antidepressants Psychotherapeutic combinations SNRI antidepressants SSRI antidepressants Tetracyclic antidepressants Tricyclic antidepressants Prescription Bupropion, Vilazodone, Vortioxetine Isocarboxazid, Phenelzine, Selegiline, Tranylcypromine Nefazodone, Trazodone Amitriptyline-chlordiazepoxide, Amitriptyline-perphenazine, Fluoxetineolanzapine Desvenlafaxine, Duloxetine, Levomilnacipran, Venlafaxine Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline Maprotiline, Mirtazapine Amitriptyline, Amoxapine, Clomipramine, Desipramine, Doxepin (>6 mg), Imipramine, Nortriptyline, Protriptyline, Trimipramine

39 Domain: Effectiveness of Care Sub-Domain: Respiratory Conditions

40 Asthma Medication Ratio (AMR) Measures the percentage of members, between the ages of 5 to 64, who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater. One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Pharmacy Administrative Measure

41 Codes to Identify AMR Codes used to identify asthma Description Asthma ICD-10-CM J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J Codes used to identify visit types Description CPT HCPCS UBREV Outpatient , , , , , , , , 99411, 99412, 99429, 99455, G0402, G0438, G0439, G0463, T , , , 0982, 0983 Observation Acute Inpatient 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253, 99254, 99255, , 0101, , , , , , 0159, 0160, 0164, 0167, 0169, , , 0219, , 0729, 0987 ED , 0451, 0452, 0456, 0459, 0981

42 Codes to Identify AMR (continued) Asthma Controller Medications Description Anti-asthmatic Combinations Inhaled Steroid Combinations Inhaled Corticosteroids Leukotriene Modifiers Mast Cell Stabilizers Methylxanthines Asthma Reliever Medications Description Short-Acting, Inhaled Beta-2 Agonists Dyphylline-guaifenesin Guaifenesin-theophylline Budesonide-formoterol Fluticasone-salmeterol Fluticasone-vilanterol Mometasone-formoterol Beclomethasone Budesonide Ciclesonide Flunisolide Fluticasone CFC free Mometasone Montelukast Zafirlukast Zileuton Cromolyn Aminophylline Dyphylline Theophylline Albuterol Levalbuterol Pirbuterol Prescriptions Prescriptions

43 Codes to Identify AMR (continued) Codes used to identify exclusions Description Acute Respiratory Failure ICD-10-CM J96.00, J96.01, J96.02, J96.20, J96.21, J96.22, Chronic Respiratory Conditions Due to Fumes / Vapors J68.4 COPD J44.0, J44.1, J44.6 Cystic Fibrosis E84.0, E84.11, E84.19, E84.8, E84.9 Emphysema J43.0, J43.1, J43.2,J43.8, J43.9

44 Domain: Effectiveness of Care Sub-Domain: Cardiovascular

45 Controlling High Blood Pressure (CBP) The percentage of 18- to 85-year-old adults who had a diagnosis of hypertension and whose blood pressure was adequately controlled in 2017 based on the following criteria: Members 18 to 59 years of age whose BP was <140/90 Members 60 to 85 years of age with diabetes whose BP was <140/90 Members 60 to 85 year of age without diabetes whose BP was <150/90 One rate reported for all three groups Data reviewed to identify compliance with measure: Medical records Hybrid Measure

46 Codes to Identify CBP Codes used to identify Members Diagnosed with Hypertension in the Outpatient Setting Description ICD-10-CM CPT HCPCS Essential Hypertension I10 Outpatient Setting , , , , , , , , 99411, 99412, 99429, 99455, G0402, G0438, G0439, G0463, T1015

47 Domain: Effectiveness of Care Sub-Domain: Diabetes

48 Comprehensive Diabetes Care (CDC) The percentage of 18- to 75-year-old adults with diabetes (type 1 and 2) who had each of the following screenings: Hemoglobin A1c (HbA1c) testing HbA1c poor control (>9.0%) HbA1c control (<8.0%) HbA1c control (<7.0%) for a Selected Population Eye exam (retinal) performed Medical attention for nephropathy that includes a nephropathy screening, monitoring test or evidence of nephropathy. Blood Pressure control (<140/90 mm Hg) Data reviewed to identify compliance with measure: Claims and encounter data Vision claims Medical records Labs Hybrid Measure

49 Codes to Identify Members with Diabetes Methods to Identify Members with Diabetes Description ICD-10-CM Diagnosis Diabetic Medications Claims Data: Diagnosis of Diabetes E10.10-E13.9, O O24.33, O O24.83 Pharmacy Data: Dispensed insulin or hypoglycemic / antihyperglycemics on an ambulatory basis Alpha-glucosidase inhibitors Amylin analogs Antidiabetic combinations Insulin Meglitinides Glucagon-like peptide-1 (GLP1) agonists Sodium glucose cotransporter 2 (SGLT2) inhibitor Sulfonylureas Thiazolidinediones Dipeptidyl peptidase-4 (DDP-4) inhibitors

50 Codes to Place of Diabetic Services Description CPT HCPCS UB Revenue Outpatient Visits / Observation , , , , , , , , , 99411, 99412, 99429, 99455, G0402, G0438, G0439, G0463, T , , , 0982, 0983 ED , 0456, 0459, 0981 Nonacute Inpatient , 99315, 99316, 99318, , Acute Inpatient , , 99238, 99239, , , 0128, 0138, 0148, 0158, , 0199, 0524, 0525, , , , 0101, , , , , , 0159, 0160, 0164, 0167, 0169, , , 0219, , 0729, 0987

51 Codes to Identify HbA1c Screening for Diabetic Members HbA1c CPT CPT-ii LOINC HbA1c Test 83036, , , HbA1c Level < 7.0 HbA1c Level HbA1c Level > F 3045F 3046F

52 Codes to Identify Retinal Eye Exams for Diabetic Members Diabetic Retinopathy CPT CTP Modifier Diabetic Retinal Screening 67028, 67030, 67031, 67036, On claims only from an eye 67039, 67040, 67041, 67042, care professional 67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225, 92226, 92227, 92228, 92230, 92235, 92240, 92250, 92260, 99203, 99204, 99205, 99213, 99214, 99215, 99242, 99243, 99244, Diabetic Retinal Screening On claims from any provider Unilateral Eye Enucleation with bilateral modifier 65091, 65093, 65101, 65103, 65105, 65110, 65112, CPT-II HCPCS ICD-10-PCS 2022F, 2024F, 2024F 3072F S0620, S0621, S3000 Two Unilateral Eye Enucleations with two services completed 14 days or more apart Left and Right Unilateral Eye Enucleations on the same or different dates of service 65091, 65093, 65101, 65103, 65105, 65110, 65112, Right Eye: 08B00ZX, 08B00ZZ, 08B03ZX, 08B03ZZ, 08B0XZX, 08B0XZZ, Left Eye: 08B10ZX, 08B10ZZ, 08B13ZX, 08B13ZZ, 08B1XZX, 08B1XZZ

53 Codes to Identify Screening / Monitoring for Nephropathy Nephropathy screening or evidence of nephropathy ICD-10-CM CPT CPT-II LOINC Urine Protein Tests , 81005, , Nephropathy Treatment Evidence of ESRD Evidence of Kidney Transplant E08.2x, E09.2x, E10.2x, E11.2x, E13.2x, I12.x, I13.x, I15.0-I15.1, N00.0 N08, N14.0-N14.4, N17.0- N19, N25.0-N26.9, Q60.0- Q61.9, R80.0-R80.9 N18.5, N18.6, Z91.15, Z99.2 Z F, 3061F, 3062F 3066F, 4010F , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

54 Codes to Identify Screening / Monitoring for Nephropathy (continued) Type of Medication Angiotensin converting enzyme inhibitors Prescription Benazepril, Captopril, Enalapril, Fosinopril, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril Angiotensin II inhibitors Antihypertensive combinations Azilsartan, Eprosartan, Losartan, Telmisartan, Candesartan, Irbesartan, Olmesartan, Valsartan Aliskiren-valsartan, Amlodipine-benazepril, Amlodipine-hydrochlorothiazide-valsartan, Amlodipine-hydrochlorothiazide-olmesartan, Amlodipine-olmesartan Amlodipine-perindopril, Amlodipine-telmisartan, Amlodipine-valsartan, Azilsartan-chlorthalidone, Benazepril-hydrochlorothiazide, Candesartanhydrochlorothiazide, Captopril-hydrochlorothiazide, Enalapril-hydrochlorothiazide, Eprosartan-hydrochlorothiazide, Fosinopril-hydrochlorothiazide, Hydrochlorothiazideirbesartan, Hydrochlorothiazide-lisinopril, Hydrochlorothiazide-losartan, Hydrochlorothiazide-moexipril, Hydrochlorothiazide-olmesartan, Hydrochlorothiazidequinapril, Hydrochlorothiazide-telmisartan, Hydrochlorothiazide-valsartan, Sacubitrilvalsartan, Trandolapril-verapamil

55 Codes to Identify Screening / Monitoring for Blood Pressure BP in the OP or Non-acute IP Setting Systolic < 140 Systolic 140 Diastolic < 80 Diastolic Diastolic 90 Outpatient Setting Non-Acute Inpatient Setting CPT CPT-II HCPCS UBREV , , , , , , , , 99411, 99412, 99429, 99455, , 99315, 99316, 99318, , F, 3075F 3077F 3078F 3079F 3080F G0402, G0438, G0439, G0463, T , , , , 0128, 0138, 0148, 0158, , 0199, 0524, 0525, , , 0669

56 Domain: Effectiveness of Care Sub-Domain: Overuse / Appropriateness

57 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) The percentage of 18- to 64-year-old adults with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Rx data Administrative measure

58 Codes to Identify AAB Codes used to identify the patient with acute bronchitis Description ICD-10-CM Diagnosis Acute bronchitis J20.3 J20.9 Co-Morbid Conditions and Competing Diagnoses That Exclude Members from the AAB Measure Codes used to identify co-morbid conditions identified 12 months prior to the diagnosis of acute bronchitis Description ICD-10-CM Diagnosis Bronchiectasis J47.0-J47.9 COPD J44.0 J44.9 Chronic bronchitis J41.0 J42 Cystic fibrosis E84.0 E84.9 Sickle Cell Disease with acute chest syndrome D57.01, D57.211, D57.411, D Emphysema J43.0 J43.9 HIV HIV Type 2 HIV asymptomatic B20 B97.35 Z21 Malignancy neoplasms C00.0- C96.Z Other diseases of the respiratory system B44.81, J22, J80- J96.92, J99, M30.1, M32.13, M33.01, M33.11, M33.21, M33.91, M34.81, M35.02 Pneumoconiosis and other lung disease due to external J60 J68.3, J68.9, J69.0 J69.8, J70 J70.9 agents Tuberculosis A15.0- A19.9, O O98.03 Disorders of the Immune System D80.0-D80.9, D81.0-D81.2, D81.4, D81.6 D81.7, D81.89, D81.9, D82.0 D82.4, D82.8 -D82.9, D83.0 D82.9, D84.0 D84.9, D89.3, D D89.813, D89.82 D89.9

59 Codes to Identify AAB (continued) Codes used to identify competing diagnoses identified 30 days prior and seven days after the diagnosis of acute bronchitis Description ICD-10-CM Diagnosis Acute Upper Respiratory Infections J02.0 J02.9, J03.00 J03.91 Infectious and Parasitic Diseases A00.0 A09, A37.00 A37.91, A44.0 A44.9, A49.9, A50.01 A59.9, A63.0 A64, A69.0 A69.9, B60.0 B64, B78.1, B96.89 Description ICD-10-CM Diagnosis Acute Upper Respiratory Infections J02.0 J02.9, J03.00 J03.91 Infectious and Parasitic Diseases H66.01-H67.9, A00.0 A09, A37.00 H A37.91, H70.93, A44.0 H95.00 A44.9, -H95.89 A49.9, A50.01 A59.9, A63.0 A64, A69.0 A69.9, B60.0 B64, B78.1, B96.89 J20.2, J32.0-J32.9, Metabolic Disorder E83.2 Disorders of the Ear H66.01-H67.9, H H70.93, H H95.89 Disorders of the Respiratory System J01.00-J03.91, J04.10, J04.11, J04.2, J05.0-J05.11, J13-J18.9, J20.0-J20.2, J32.0-J32.9, Digestive System Diseases K12.2 Integumentary System Diseases M46.20-M46.39, L01.00-L01.1, L L04.91, M89.00-M89.9, L08.1-L08.9, M90.80-M90.89 L88, L92.8, L98.0, L98.3 Musculoskeletal System and Connective Tissue Disease M46.20-M46.39, M89.00-M89.9, M90.80-M90.89 Genitourinary Diseases N30.91, N10-N12, N39.0, N13.0, N41.0-N41.9, N13.6, N15.1, N70.01-N77.1, N16, N28.84-N28.86, N N30.91, N39.0, N41.0-N41.9, N70.01-N77.1, Health Hazards Related to Communicable Diseases Z20.2, Z22.4 Metabolic Disorder E83.2 Disorders of the Ear Disorders of the Respiratory System Digestive System Diseases K12.2 J01.00-J03.91, J04.10, J04.11, J04.2, J05.0-J05.11, J13-J18.9, J20.0- Integumentary System Diseases L01.00-L01.1, L L04.91, L08.1-L08.9, L88, L92.8, L98.0, L98.3 Musculoskeletal System and Connective Tissue Disease Genitourinary Diseases Health Hazards Related to Communicable Diseases Z20.2, Z22.4 N10-N12, N13.0, N13.6, N15.1, N16, N28.84-N28.86, N30.00-

60 Use of Imaging Studies for Low Back Pain (LBP) The percentage of members between the ages of 18 and 50 with a primary diagnosis of low back pain who did not have an imaging study within 28 days of the diagnosis. One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Administrative measure

61 Codes to Identify LBP Codes used to identify uncomplicated low back pain Description Uncomplicated low back pain ICD-10-CM M47.26, M47.27, M47.28, M47.816, M47.817, M47.818, M47.896, M47.897, M47.898, M48.06, M48.07, M48.08, M51.16, M51.17, M51.26, M51.27, M51.36, M51.37, M51.86, M51.87, M53.2X6, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, M54.16, M54.17, M54.18, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M54.5, M54.89, M54.9, M99.03, M99.04, M99.23, M99.33, M99.43, M99.53, M99.63, M99.73, M99.83, M99.84, S33.100A, S33.100D, S33.100S, S33.110A, S33.110D, S33.110S, S33.120A, S33.120D, S33.120S, S33.130A, S33.130D, S33.130S, S33.140A, S33.140D, S33.140S, S33.5XXA, S33.6XXA, 533.8XXA, 533.9XXA, S39.002A, S39.002D, S39.002S, S39.012A, S39.012D, S39.012S, S39.092A, S39.092D, S39.092S, S39.82XA, S39.82XD, S39.82XS, S39.92XA, S39.92XD, S39.92XS

62 Codes to Identify LBP (continued) Codes used to identify outpatient visits type of clinic encounter Description CPT Outpatient , , , , , , , , 99411, 99412, 99429, 99455, With or Without Telehealth Modifier -95 -GT HCPCS G0402, G0438, G0439, G0463, T1015 UBREV , , , 0982, 0983 Observation ED , 0456, 0459, 0981 Osteopathic or Chiropractic , Physical , 97124, Therapy 97140, Telephone Visit , Online 98696, Assessment

63 Domain: Effectiveness of Care Sub-Domain: Medication Management

64 Annual Monitoring for Patients on Persistent Medications (MPM) The percentage of adults, 18 years of age and older, who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and had at least one therapeutic monitoring event for the therapeutic agent during the measurement year. Three rates are reported for the following therapeutic agents: Angiotensin Converting Enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) Digoxin Diuretics Total rate Data reviewed to identify compliance with measure: Claims and encounter data Pharmacy Data Labs Administrative measure

65 Codes to Identify MPM Codes used to identify therapeutic monitoring events Description CPT LOINC Digoxin Level , Lab Panel 80047, 80048, 80050, 80053, Serum Potassium 80051, , , , , , , , , , , , , Serum Creatinine 82565, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

66 Domain: Access and Availability of Care

67 Children & Adolescents Access to PCPs (CAP) The percentage of members: 12 months to 6 years old who had a visit with a PCP during the measurement year (2017) 7 to 19 years old who had a visit with a PCP during the measurement year (2017) or the year prior to the measurement year (2016) Four rates are reported for the following age groups: 12 to 24 months 25 months to 6 years 7 to 11 years 12 to 19 years Data reviewed to identify compliance with measure: Claims and encounter data Administrative measure

68 Codes to Identify CAP Codes used to identify Children and Adolescents Access to Primary Care Practitioners Description ICD-10-CM Diagnosis CPT HCPCS UB Rev Ambulatory Visit Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0- Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z , , , , , , , , 99411, 99412, G0402, G0438, G0439, G0463, T , , , 0982, 0983

69 Prenatal & Postpartum Care (PPC) The percentage of women with live birth deliveries, between November 6, 2016 and November 5, 2017, who had prenatal and postpartum care visits. Two rates are reported: Timeliness of Prenatal Care: The percentage of women who had a prenatal care visit during the first trimester or within 42 days of enrollment with their health plan Postpartum Care: The percentage of women who had a postpartum care visit between 21 and 56 days after delivery Data reviewed to identify compliance with measure: Claims and encounter data Medical records Hybrid measure

70 Codes to Identify Members for Prenatal and Postpartum Care Measure Codes used to identify Prenatal Services Within the First Trimester for within the first 42 Days of Enrollment Description CPT CPT II HCPCS ICD-10-PCS LOINC UBREV Prenatal Bundled Services Billed On the Date of Delivery 59400, 59425, 59426, 59510, 59610, H1005 Prenatal Visits 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, Obstetric Panel 80055, Value Prenatal Ultrasound 76801, 76805, 76811, 76813, , Antibody Screenings: Toxoplasma, Rubella, Herpes Simples, Cytomegalovirus 86644, 86694, 86695, 86696, 86762, 86777, 86778, 86900, F, 0501F, 0502F H1005, H1000, H1001, H1002, H1003, H1004 G0463, T1015 BY49ZZZ, BY4BZZZ, BY4CZZZ, BY4DZZZ, BY4FZZZ, BY4GZZZ Click here for a complete list of 198 LOINC codes related to the specified antibody screenings. 0514

71 Codes to Identify Members for the Prenatal and Postpartum Care Measure Codes used to identify Postpartum Services within 21 to 56 Days After Delivery Description CPT CPT II HCPCS ICD-10-CM LOINC UBRE V Postpartum Bundled Services 59400, 59410, 59510, 59515, 59610, 59614, 59618, Postpartum Services 57170, 58300, 59430, Cervical Cytology 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, F G0101 Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2 G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q , , , , , , , , ,

72 Domain: Utilization and Risk Adjusted Utilization

73 Well-Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life (W34) The percentage of 3- to 6-year-old children who had one or more well-child visit(s) with a PCP in 2017 and the provider of care assessed and documented ALL of the following: Health history Physical developmental history Mental developmental history Physical Exam Health education / anticipatory guidance One rate reported Data reviewed to identify compliance with measure: Claims and encounter data Medical records Hybrid measure

74 Codes to Identify W34 Codes used to identify Well Child Visits Description CPT HCPCS ICD-10 Newborn Care Services (28 Days Old or Less) New Patient Preventive Medicine Services Established Patient Preventive Medicine Services Annual Wellness Visit Wellness Exams G0438 G0439 Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89,

75 Ambulatory Care (AMB) This measures summarizes utilization of ambulatory care in 2017 in the outpatient and emergency department. Two rates reported: Outpatient utilization Emergency Department utilization Data audited to identify compliance with measure: Claims and encounter data Administrative measure

76 Codes to Identify AMB Description CPT HCPCS UBREV POS Outpatient 92002, 92004, 92012, 92014, , , , , , 99318, , , , , , , , , 99420, 99429, G0463, T , , ED Visit Only ED Procedure , 0456, 0459, 0981 Click here to see the complete list of 5,777 CPT codes related to ED procedures. 23

77 Reasons for Low HEDIS Rates

78 Reasons for Low HEDIS Rates Clinics did not submit claims or encounter data - No data = No history of services performed Coding on claims and encounter data is incomplete or inaccurate - Incomplete or inaccurate coding = No history of services performed Delayed claims and encounter submissions Medical record documentation is incomplete Patients did not receive annual screenings Patients with chronic conditions are not monitored Patients on persistent medications are not monitored Clinics are not familiar with HEDIS measure criteria

79 How to Improve Your HEDIS Rates

80 How to Improve Your HEDIS Rates Timely submission of all claims and encounter data Complete and accurate coding of all services performed Document all services and care provided in the medical record - Include child and adolescent counseling for nutrition and physical activity Schedule patients for their annual screenings and check-ups - Children are expected to have annual check-ups Continually monitor patients with chronic conditions Continually monitor patients on persistent medications Understand the HEDIS measure criteria and the standard practice guidelines

81 2017 Medical Codes for HEDIS Reporting To obtain a complete list of the medical codes used by NCQA to identify compliance with HEDIS measures, click on the following link: NCQA s Quality Rating System HEDIS Value Set Directory or visit

82 HEDIS Questions? Please HEDIS questions to